Coumadin alternatives ?????

[Missouri Dave]

My father in law will be undergoing hip replacement surgery at the end of this month. The doctor has told him he needs to take coumadin to thin his blood. My in laws very much prefer alternative medicine and called me to research what alternative could be used. I suggested yarrow, hawthorne berry extract, garlic and a few others. Now, none of these will be used without discussing it with his doctor, what do you recommend?

[DrBaboon]

I don't think anyone is going to try to tell you what he should do, or how to do it, as that would be medical advice when none of us know enough about his specific individual situation.

That being said... I predict he will have a difficult time getting his orthopedic surgeon to cooperate with such a request.

There are no doubt people who will say somethings like "well - Duh! - doctors *are like that* ".

That's not what I meant.

Deep Vein Thrombosis and Pulmonary Embolism are common complications of many types of orthopedic surgery - especially repair of hip fracture OR hip replacement (without a fracture). It's an area within medicine that has a lot of research, and has lead to protocols, and statements of STANDARDS OF CARE, which are derived from so-called Evidence Based Medicine.

http://www.emedicine.com/orthoped/topic600.htm this is a good summary.

Scroll down - there are numerous sections relevant to your question - but I'll quote these guidelines in particular:

The ACCP provides recommendations for specific treatment of patients following THRs as follows:

* Postoperative LMWH 12-24 hours after surgery or 4-6 hours after surgery at one half the dose initially followed by a full dose on the next day or preoperatively 12 hours before surgery followed by a full dose 12-24 hours postoperatively.

* Warfarin preoperatively or immediately postoperatively with INR range of 2-3 (target INR of 2.5)

* Adjusted-dose heparin

* Adjuvant prescription with ES or IPC

* LDH, aspirin, dextran, or IPC alone not recommended

This tells you that there are a number of other interventions with alter clotting, but *do not* offer sufficient degrees of protection from DVT following THR. Your problem is that even if you find that any, some, most or even all of the herbals you mentioned have an effect, is that effect sufficiently powerful to produce outcomes that are close to what is being achieved with warfarin or LMWH.

I personally know a number of physicians who have lost medical malpractice lawsuits for not following these guidelines - even when they recognized and documented reasons for *not* following the guidelines in the patient's chart. Someone decided after the fact that the reason identified for not following the guidelines was not sufficient.

IOW - aside from a lack of familiarity with the herbs which interest you, aside from whether there are studies which demonstrate the outcomes of using such herbs in a head-to-head comparison with warfarin or LMWH as STANDARDS OF CARE in THR...

Aside from those considerations...

Recognize you are asking an orthopedic surgeon to do something they know with certainty they can be sued for doing. Don't assume the orthopedic surgeon is being a jerk for being unwilling to expose themselves to that kind of risk, *and* do what they probably believe is less than good care for their patient. Regardless of what your relative does, take this into account in your discussions with the surgeon and any other physicians who might become involved in his care.

There is always patient autonomy. People can refuse warfarin or LMWH or whatever. The question is whether the orthopedic surgeon trusts your family to be honorable people, and take on the responsibility for those decisions, and not blame him/her for agreeing to your requests. What are you going to do to give them that assurance? Basically, you can sign all the papers in the world, and that will not prevent you from changing your mind and suing the surgeon for listening to you.

To put it another way, whether you mean it or not, it is likely the surgeon will interpret your request as hostile and threatening. Not questioning their knowledge or being "uppitty" or whatever, but as literally doing something like planning to take away their retirement plan or their kid's schooling. Knowing that *might* help you to communicate your interests and offer whatever assurances you can that you understand that your request is for them to deviate from compelling STANDARDS OF CARE.

So, it's maybe not the advice you're looking for, but nonetheless applicable to your situation.

The separate issue is to get as much well-done research on herbals as is possible, and to be able to know how to use them as drugs.

I don't have the time today to do searches on each of the products you mentioned and type an analysis of them. If there are others on the board who already have that information, I'd love to have a separate discussion of using them under austere circumstances.

[Missouri Dave]

WOW! Thanks for the info Doc! Put that way I'm sure your right. If I were the doctor I wouldn't risk a lawsuit or my license for what would be a clear violation of the standard of care either. Thanks again for the response.